Case Report TADs assisted Camouflage Orthodontic Treatment of Class II Division 1 Malocclusion in a Non Growing Patient: A case report Dr Ankita Gupta,1 Dr Trilok Shrivastava2 1Consultant Orthodontist, Department of Orthodontics, Cure Dent Smile designing center, Pune, India, 2Reader, Department of Orthodontics, People's Dental Academy, Bhopal, India Correspondence: Dr. Ankita Gupta; Email: [email protected] ABSTRACT Class II, Division I malocclusion has been described as the most frequent treatment problem in orthodontic practice. Aim & objectives of the present case report was to evaluate the management of skeletal Class II division 1 malocclusion in non growing patient with extraction of upper first premolars. Clinical and cephalometric evaluation revealed skeletal Class II with Angles Class II division 1 malocclusion with mild mandibular anterior crowding and increased overjet, severe maxillary incisor proclination, mild mandibular crowding, exaggerated curve of spee, convex profile, incompetent lips, increased overjet and overbite. Maxillary first premolars were extracted followed by en-masse retraction of anteriors with the help of temporary anchorage devices (TADs) to avoid anchorage loss. Mandibular incisor was extracted to correct curve of spee. Following treatment marked improvement in patient’s smile, facial profile and lip competence were achieved and there was a remarkable increase in the patient’s confidence and quality of life. Keywords: Anchorage loss, Class II div1 malocclusion, Non growing patient, TADs (temporary anchorage devices). INTRODUCTION the mandibular arch.4,5 Studies have shown that patient satisfaction with camouflage treatment is similar to that Non-growing patients with skeletal Class II malocclusions achieved with surgical mandibular advancement6 and can be treated by only two possible treatment approaches: that treatment with two maxillary premolar extractions (1) orthodontic camouflage, based on selective gives a better occlusal result than treatment with four extraction of permanent teeth followed by retraction of premolars extractions. the protruding maxillary incisors to improve both dental occlusion and facial aesthetics without correcting the Anchorage control plays a pivotal role in the effective underlying skeletal problem; or (2) orthognathic surgery management of orthodontic patients for obtaining both to reposition the mandible or the maxilla. Skeletal Class II structural and facial esthetics. Anchorage is defined 7,8 problems are due to mandibular deficiency or downward- as the resistance to unwanted tooth movement or as backward rotation of the mandible caused by excessive the desired reaction of posterior teeth to space closure vertical growth of the maxilla. Surgical treatment, mechanotherapy. Obtaining maximum or absolute therefore, consists of mandibular advancement, superior anchorage has always been an ultimate goal for the repositioning of the maxilla, or a combination. Mandibular practicing orthodontist, often resulting in a condition, deficiency is the problem in about two thirds of surgical called anchorage loss. Anchorage loss is the reciprocal patients; one third require maxillary surgery, either alone reaction of the anchor unit that can obstruct the success (15%) or combined with mandibular surgery (20%).1 of orthodontic treatment by complicating anteroposterior correction.9 To address this problem, many appliances Premolars are probably the most commonly extracted and techniques have been devised; Nance holding arch, teeth for orthodontic purposes as they are located transpalatal bars, extraoral traction, multiple10 teeth at the between the anterior and posterior segments. For anchorage segment, and differential moments11,12 are correction of Class II malocclusions in non-growing some commonly used ones. However, all these methods patients extractions can involve 2 maxillary premolars2 or have a few inherent disadvantages - complicated designs, 2 maxillary and 2 mandibular premolars3 The extraction need for exceptional patient cooperation, elaborate wire of only 2 maxillary premolars is generally indicated when bending, and so on. there is no crowding or cephalometric discrepancy in 55 Orthodontic Journal of Nepal, Vol. 8 No. 2, December 2018 Gupta A, Shrivastava T : TADs assisted Camouflage Orthodontic Treatment of Class II Division 1 Malocclusion in a Non Growing Patient: A case report In past few years, titanium screws have gained enormous lips, acute nasolabial angle and symmetrical face. popularity in the orthodontic community and are Retrognathic mandible was observable. Intraoral being considered as absolute sources of orthodontic examination revealed severely proclined maxillary anchorage.13-15 Their primary advantages are easy anteriors, increased overjet with mandibular mild placement and removal, immediate loading, placement anterior crowding with increased curve of spee. at various anatomic locations including alveolar bone Molars and canines were in Class II relation. (Figure 1). between roots of teeth, and low cost. These screws have Cephalometric analysis showed skeletal Class II with spawned many clinical applications, such as en-masse retrognathic mandible with low angle (Figure 2). retraction of anterior teeth. The primary treatment objectives were to reduce the Lower incisor extraction can be regarded as a valuable increased overjet, levelling of exaggerated curve of option in the pursuit of excellence in orthodontic results in spee, and improve the smile of patient. Patient was terms of function, aesthetics and stability. This treatment banded and bonded with 0.022 slot MBT prescribed option is also indicated in Class II Division 1 skeletal and bracket in both arches. Maxillary first premolars in both dental malocclusions with maxillary protrusion and the quadrants were extracted to gain spaces required crowding or protrusion of the lower incisors. Typically, lower for retracting anteriors. Lower incisor was extracted to incisor extraction should be associated with the extraction reduce mild crowding and level curve of spee in lower of maxillary premolars while keeping the Class II molar arch. Leveling and alignment was started with the use relationship but establishing normal canine occlusion. of 0.014 NiTi, 0.016 NiTi with lacebacks and bendbacks CASE REPORT to prevent anchorage loss. In mandibular arch, incisors were intruded, to correct deep bite by intrusion arch A 19-year-old male patient came for orthodontic (0.017 x 0.025 TMA) and activated by a molar tip back treatment with convex facial profile, incompetent bend. Figure 1: Pre-treatment photographs 56 Orthodontic Journal of Nepal, Vol. 8 No. 2, December 2018 Gupta A, Shrivastava T : TADs assisted Camouflage Orthodontic Treatment of Class II Division 1 Malocclusion in a Non Growing Patient: A case report Figure 2: Pre-treatment cephalograph After the initial levelling and aligning, TADs (1.5/8 mm) interdigitation, inclination, angulation, ideal overjet were placed between second premolar and first molar and overbite. Debonded and retention was given by for anterior retraction in first and second quadrants fixed retainers and upper & lower Hawley’s retainers. and extraction spaces were closed using power Patient was advised to follow up in retention period. chains. Final settling of occlusion was done with proper (Figure 3-6) Figure 3: A, B and C - Leveling and Alignment-022 Edgewise Bracket system placed with 0.014 NiTi archwire Figure 4: D,E and F - Leveling and Alignment Follow up 0.016 NiTi and Intrusion arch 0.017 x 0.025 TMA wire Figure 5: G,H and I – Anterior retraction with TADs 0.019 x 0.025 SS 57 Orthodontic Journal of Nepal, Vol. 8 No. 2, December 2018 Gupta A, Shrivastava T : TADs assisted Camouflage Orthodontic Treatment of Class II Division 1 Malocclusion in a Non Growing Patient: A case report Figure 6: J, K and L - After 6 months of space closure Figure 7: Post-treatment photographs Post treatment assessment managed by contemporary orthodontic technique with TADs without the anchorage loss. Lip competence and a straight profile were achieved, improving the patient’s facial appearance. A CONCLUSION functional occlusion with normal overjet and overbite; Camouflage treatment of Class II malocclusion in adults (Figure 7). Duration of the treatment was 21 months. is challenging. Extractions of premolars, if undertaken The patient and her parents were very happy with after a thorough diagnosis often leads to positive profile complete satisfaction. changes and an overall satisfactory facial esthetics. A well chosen individualized treatment plan, undertaken DISCUSSION with sound biomechanical principles and appropriate Patient had improved smile and profile after orthodontic control of orthodontic mechanics to execute the plan treatment. Upper incisors were retracted to achieve is the surest way to achieve predictable results with normal incisor inclinations, overjet and overbite. minimal side effects. Bilateral Class I canine relation was achieved with maximum intercuspation. The case was successfully OJN 58 Orthodontic Journal of Nepal, Vol. 8 No. 2, December 2018 Gupta A, Shrivastava T : TADs assisted Camouflage Orthodontic Treatment of Class II Division 1 Malocclusion in a Non Growing Patient: A case report REFERENCES 1. Proffit WR, White RP, Sarver DM. Contemporary treatment of dentofacial deformity. St. Louis: Mosby; 2003. 2. Cleall JF, Begole EA. Diagnosis and treatment of Class II Division 2 malocclusion. Angle Orthod 52:38-60; 1982. 3. Strang RHW. Tratado